HIV/AIDS and the risk of deep vein thrombosis: a study of 45 patients with lower extremity involvement.

Many aspects of acquired immunodeficiency syndrome (AIDS) have been described in detail in the literature. However, there have been very few articles on the phenomenon of deep vein thrombosis (DVT) in the lower extremities of human immunodeficiency virus (HIV)/AIDS patients. The objective of this communication is to record the incidence of DVT in HIV/AIDS patients and the risks for development of embolic events and to emphasize the need for prevention and for the vigorous treatment of this complication. We conducted a retrospective review of HIV/AIDS-infected patients with DVT admitted to Mount Sinai School of Medicine/Cabrini Hospital in New York during the last 5 years. Analysis includes demographic data; risk factors for HIV/AIDS infection; associated medical problems; recent surgery; and laboratory findings including CD4 counts, platelet counts, prothrombin times, partial thromboplastin times, and plasma albumin levels; and image studies. From January 1995 to January 2000 4752 HIV/AIDS-infected patients were admitted. Of those admitted to the hospital 45 (0.95%) were found to have DVT. There were 36 males and nine females (mean age 43 years). Of the 45 patients 38 had infectious complications and 13 developed a malignancy. The distribution of the thromboses were the femoral vein in 23 patients, the popliteal vein in 20 patients, and the iliofemoral system in 2 patients. Twelve patients had recurrent DVT and three patients developed a pulmonary embolism. HIV/AIDS infection is a considerable risk for development of DVT in the lower extremity. Statistically DVT in HIV/AIDS is approximately 10 times greater than in the general population. Emphasis upon prevention and vigorous treatment of DVT is recommended.

Changes in liver function tests after laparoscopic cholecystectomy: not so rare, not always ominous.

The incidental findings of increased alanine aminotransferase (ALT) and aspartate amino transferase (AST) after uneventful laparoscopic cholecystectomy (LC) prompted us to investigate the incidence and the clinical significance of this phenomenon. Changes in liver function test after LC (n = 55) were compared with those after OC (n = 16). Liver function tests were obtained preoperatively and postoperatively on days 1, 2, and 7. All of the patients fulfilled the selection criteria: normal preoperative liver function test and no endoscopic retrograde cholangiopancreatography, common bile duct exploration, or postoperative biliary complications (injury, infection, or obstruction). Converted cholecystectomies were also excluded. During LC, the intra-abdominal pressure was maintained within the conventional range of 14 to 15 mm Hg. ALT had doubled in the first 48 hours from the preoperative mean in 58.2 per cent in LC patients versus only 6.3 per cent in the OC group. AST doubled from the preoperative mean value in 38.2 per cent in the LC group versus only 6.3 per cent in the OC group. By the 7th postoperative day, the enzymes returned to the preoperative values in both the LC and the OC group. In many instances, a significant increase in ALT and AST blood levels occurred after uneventful LC. The phenomenon is transient as these enzymes returned to normal value within 7 days. These changes are clinically silent in patients with a normal liver function.

Surgical treatment of HIV-related immune thrombocytopenia.

Immune related thrombocytopenia has been described extensively in patients infected with the human immunodeficiency virus (HIV). The efficacy and safety of splenectomy performed in 21 patients affected with HIV-related immune thrombocytopenia (platelet count less than 50,000/mm3), between 1992 and 1996, were evaluated. All the patients were symptomatic and had failed medical therapy. Nine of them were affected with acquired immune deficiency syndrome (AIDS), whereas 12 were HIV-positive (non-AIDS). In all the patients, a pre-operative bone marrow biopsy revealed increased megakaryocytes. Follow-up ranged from 5-16 months. The response rate to splenectomy (platelet count greater than 100,000/mm3) in the AIDS group was 83%, as opposed to 100% in the HIV-positive (non-AIDS) group. During the follow-up period, 19 of the 21 patients maintained platelet counts greater than 98,000/mm3; of the two non-responders, one patient expired 3 weeks after surgery, and a second patient had never responded. None of the HIV-positive (non-AIDS) patients developed AIDS during the follow-up period. All the complications observed (24%) were treated without sequelae. Based on these data, splenectomy can be considered safe and effective in treating patients with symptomatic HIV-related thrombocytopenia, when medical therapy has failed. Moreover, splenectomy did not appear to adversely affect the rate of conversion from the HIV-positive to the AIDS status, nor did it accelerate the progression of the disease in patients already diagnosed with AIDS.

Skin necrosis in the presence of paclitaxel and fluorometholone.

Paclitaxel (Taxol) can induce full-thickness skin necrosis at sites distant from those of injection. This side effect may be potentiated in the presence of fluorometholone (FML).

Early experience in the use of the Advanced Breast Biopsy Instrumentation: a report of one hundred twenty-seven patients.

BACKGROUND: Recently there has been a great interest in developing alternative breast biopsy techniques that yield the appropriate histologic information in the least invasive and most cost-effective manner. The objective of this study was to evaluate the efficacy and results with the Advanced Breast Biopsy Instrumentation (ABBI) method for stereotactic excisional biopsies of nonpalpable mammographically detected breast lesions. METHODS: All patients with nonpalpable mammographic abnormalities who fulfilled the selection criteria for the ABBI procedure were studied. Pathologic diagnosis, the size of the specimen, the length of the procedure, postoperative complications, patient satisfaction, and the cost of the ABBI procedure were analyzed. RESULTS: One hundred twenty-seven of 139 patients (94.2%) underwent the ABBI procedure. Twelve patients (8.61%) required conversion to the needle localization procedure. Mammographically, 64 lesions revealed microcalcifications, 51 showed nodular densities, and 12 demonstrated both findings. Histologically, 21 lesions (16.5%) were malignant, whereas 106 were benign (83.5%). The mean operative time for the procedures was 62.5 minutes. Postoperatively 5 patients had local ecchymosis and 1 had a hematoma. The average cost per patient was found to be $1000, considerably less than for needle localization biopsy. CONCLUSION: With proper patient selection the ABBI procedure has proved to be a valuable tool in the armamentarium of the breast surgeon. Its efficiency, accuracy, and patient acceptance have been well documented in our hands.

Open and laparoscopic cholecystectomy in acquired immunodeficiency syndrome: indications and results in fifty-three patients.

BACKGROUND: Although acute cholecystitis is one of the most common indications for abdominal surgery in patients with acquired immunodeficiency syndrome (AIDS), previous studies have reported disappointingly high morbidity and mortality among those patients who have undergone cholecystectomy. The aims of this study were to analyze the indications for and the outcome of cholecystectomy performed for acute cholecystitis in patients with AIDS. METHODS: We retrospectively reviewed the hospital charts of 53 patients with AIDS who underwent open or laparoscopic cholecystectomy from 1992 to 1997. Statistical analysis using the chi-square, Student's t, and Fisher exact tests was conducted to determine whether cause of cholecystitis, type of surgical approach, and CD4+ T-lymphocyte count influenced outcome. RESULTS: The clinical findings and imaging by ultrasonography were always reliable in establishing diagnosis and guiding treatment of acute cholecystitis. Open cholecystectomy was performed in 24 patients (45%). The procedure was begun laparoscopically in 29 patients (55%) and converted to open in 4 (14%). The pathologic findings showed acalculous cholecystitis in 19 patients (36%) and cholelithiasis in 32 (60%). Morbidity was 34% and mortality was 2%. Type of operative approach, cause of cholecystitis, and CD4+ T-lymphocyte count (greater or less than 50 cells/mm3) did not significantly affect morbidity and mortality. The length of hospital stay was significantly influenced by the CD4+ T-lymphocyte count. CONCLUSIONS: These findings suggest that in most patients with AIDS, laparoscopic or open cholecystectomy may be performed with significant but acceptable morbidity and low mortality.

Correlation between low neuraminidase blood levels and a predisposition toward family-related breast cancer.

It has been shown that high sialic acid levels are often found in conjunction with breast cancer, and these high concentrations are thought to be due to deficiency of the enzyme neuraminidase. The study proposes to elicit a relationship between low levels of blood neuraminidase and a family history of breast cancer. Neuraminidase blood levels were measured in 30 healthy women between the ages of 35 and 65 years with no evidence of a family history of breast cancer (control group), and in 33 healthy women between the ages of 35 to 65 years, all of whom had immediate members of their families with breast cancer (study group). The mean level of the blood neuraminidase was found to be 1.375 units in the control group. On the other hand, the mean level for the study group was 1.256 units. The difference between the two groups is statistically significant, (P value < 0.01). It is important to note that in the study group 20 of the 33 participants, 60.6 per cent, had neuraminidase levels below the mean of the study group, whereas only 3 of the 30, 10 per cent, in the control group had neuraminidase levels below the mean of the study group. Deficiency of the enzyme neuraminidase may suggest an elevated risk for breast cancer.

Foregut duplication cyst: a report of a case.

During the early embryonal stage of foregut development, malformations may be encountered. Foregut duplications are considered to be due to abnormal cannulization of the gastrointestinal tract and may be communicating or non-communicating cystic or tubular. They are lined by mucosal membrane. The case herein records the first instance of a foregut duplication cyst that contained both gastric and bronchial mucosa. The patient was a 35-year-old female complaining of epigastric pain and nausea for the past several months. Physical examination revealed no abnormal findings, but an upper gastrointestinal X-ray series demonstrated an irregularity of the greater curvature of the stomach. On CT scan, a left upper quadrant mass was noted. At laparotomy, a soft, retroperitoneal mass was seen between the stomach and the left adrenal gland, measuring 5.5 x 2.5 x 2 cm. It was excised and sent for histopathology. Pathology showed the mass to be of a cystic nature, containing both gastric and bronchial mucosa. After surgery the patient made an uneventful recovery.

Elective cholecystectomy and carcinoma of the gallbladder.

The incidence of carcinoma of the gallbladder has been reputed to be approximately 1.5 per cent among those who undergo surgery for chronic cholecystitis. The incidence at Cabrini Medical Center coincides rather well with that from other studies but has shown a marked decline, 21.5 per cent, within recent years. A report from the American Cancer Society projects an even greater decline to 0.65 per cent in the incidence of this almost incurable disease within the next 1-2 years. The decrease in the incidence of cancer of the gallbladder is attributed to the great increase in the performance of elective cholecystectomy for chronic cholecystitis among people 50 years of age or younger, before they have reached the age when carcinoma of the gallbladder is most prevalent. Early surgery is advocated not only as an effective and safe form of therapy but also as a valuable preventive measure.

The incidence of intra-abdominal surgery in acquired immunodeficiency syndrome: a statistical review of 904 patients.

This communication concerns the incidence of intra-abdominal surgery in 904 patients with acquired immunodeficiency syndrome who were admitted to the Cabrini Medical Center during a 3-year period from January 1985 to January 1988. It was found that 36, or 4.2%, of the patients underwent surgery, including 12 cholecystectomies, 7 splenectomies, 7 appendectomies, 6 laparotomies, and 6 other operations for miscellaneous conditions. It was pointed out that the high incidence of inflammatory involvement of the gallbladder, appendix, and intestines in AIDS patients was in all probability due to the nature of the blood supply to these organs. All receive blood from terminal arteries or vessels with few anastomoses, and therefore when vasculitis ensues it is often followed by gangrene or ulceration of mucosal surfaces. Surgical intervention was deemed advantageous for those patients with splenomegaly and accompanying pancytopenia, acute appendicitis, and lesions of the gastrointestinal tract, but not for those with cholecystitis. The high postoperative mortality rate, 22.2%, was attributed primarily to the immunodeficient state of the patients rather than to complications of their surgery.

The surgical treatment of the Zollinger-Ellison syndrome: an update.

Forty-six professors of surgery in answers to a questionnaire reported that 143 patients with Zollinger-Ellison syndrome had been admitted to their hospitals within the last 2 years. The bed capacity of these hospitals totaled 27,019. In extrapolating these figures, it is seen that the capacity of the 46 institutions averaged 587 beds per hospital, and that an average 71.5 patients with Zollinger-Ellison syndrome were admitted each year. In other words, a hospital with 587 beds might expect 1.55 yearly admissions of patients suffering from this disease. Two surgical methods have emerged as today's main treatment choices for Zollinger-Ellison syndrome that is unaccompanied by isolated gastrinoma. These are 1) preoperatively administered H2 blockers followed by less-than-total gastrectomy, truncal vagotomy, and postoperative H2-blocker therapy; and 2) preoperatively administered H2 blockers followed by highly selective vagotomy plus postoperative H2-blocker therapy. Only seven of 46 respondents still maintain that total gastrectomy should be carried out to cure the disease. All respondents advocate excision of an isolated gastrinoma as the treatment of choice if one is found at surgery.

Continuous epidural analgesia in the heparinized vascular surgical patient: a retrospective review of 912 patients.

Nine hundred twelve patients received continuous epidural analgesia administered through an indwelling plastic catheter while undergoing vascular reconstruction of a lower extremity. During a portion of the operative event, the patients were totally, transiently anticoagulated with heparin. None of the patients had an untoward neurologic event that could be attributed to an epidural hematoma. Our results and those of others show that this form of regional analgesia is safe and far outweighs theoretic contraindications when anticoagulation with heparin is planned as a part of the operative event. In the patients with impaired pulmonary ventilation or a cardiac disorder, this method of analgesia offers many advantages over a general anesthetic, such as obviating aspiration pneumonitis and averting prolonged support in the recovery period after completion of the surgical procedure. The regional vasodilation ensuing from the epidural blockade is an additional advantage in patients undergoing vascular reconstruction for lower extremity ischemia.

Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) in penetrating trauma of the pancreas.

Assessment of the integrity of the ductal system of the pancreas after a penetrating injury is mandatory and can prevent potentially fatal complications. The authors report a case in which the endoscopic retrograde cholangiopancreatography (ERCP) was employed intraoperatively to carry out such assessment after a pancreatic stabwound.

Cold nodules of the thyroid: current treatment.

Within recent years differing approaches to the treatment of cold nodules of the thyroid gland have evolved. To assess these differences and to discover whether a general consensus exists, questionnaires were sent to professors of surgery and endocrinology and to chiefs of head and neck sections at various medical colleges and university hospitals throughout the country. Fifty-three surgeons and 13 endocrinologists answered the questionnaires and their responses are analyzed and recorded here.

Peritoneal lavage as an aid to diagnosis of peritonitis in debilitated and elderly patients.

Twenty-seven debilitated or obtunded patients were subjected to peritoneal lavage to determine the presence or absence of peritonitis. Fourteen lavages were found to be positive, revealing peritonitis in 12 patients. Two of the 14 patients refused surgery and subsequently died. Thirteen patients had negative lavages, none of whom subsequently developed any evidence of peritonitis or required surgical intervention. Peritoneal lavage is an extremely reliable procedure, both in establishing the diagnosis of peritonitis or in ruling out its presence in debilitated or obtunded, elderly patients. The procedure can be performed quickly, without prolonged preparation, and without fear of complications. In addition, there is little cost to the procedure, especially when compared to the cost of more sophisticated time-consuming tests such as x-ray studies, gallium or CT-scanning.

Coexistence of abdominal aortic aneurysm and carcinoma of the colon: a dilemma.

The incidence of colonic cancer coexisting with an aneurysm of the abdominal aorta is approximately 2%. Such a coexistence presents a true dilemma to the surgeon for it is often difficult to decide whether to treat the carcinoma or the aneurysm first. This report summarizes the opinions of 46 Professors of General Surgery and Vascular Surgery who gave their response as to which condition should receive priority of treatment. Approximately one third of the respondents favored excision of the carcinoma first; one third stated they would excise the aneurysm first; and the remaining third said they would withhold a decision until laparotomy was performed. Two surgeons replied that they would attempt to perform aneurysmectomy and colectomy simultaneously.